Health History Form

If you would like to submit an online Health History form to us, please fill out the following
information as completely as possible. We'll then contact you to set up an appointment.

Contact Info All fields in this section are required unless marked optional

Name:

Address:

City:State:Zip:

Email:

Phone: (ex: 212-123-4567)

Mobile: (optional)

Appointment times you prefer: (optional)

WeekdayWeekend

MorningAfternoonEvening

Personal Questionnaire

Age:

Height:

ft.

in.

Gender:

MaleFemale

Relationship:

SingleMarriedDivorcedIn a relationship

Children?

YesNo

Please tell us how we can help you. What are your main concerns?

Occupation:

How many hours per week do you work?

How many hours a week do you exercise?

Current weight:

lbs.

One year ago:

lbs.

Desired weight:

lbs.

Do you sleep well?

YesNoSometimes

On average, how many hours do you sleep each night?

What percentage of your food is home-cooked?

What do you feel your "bad" addictions are? (Please check all that apply.)

CaffeineSugarBaked goods/sweets

AlcoholFried FoodsSmoking

Others:

What are your favorite foods? (Don't worry, we'll find a way to let you still enjoy these foods.)

Please check all that apply.

Feel tiredLack energyFeel depressed

High cholesterolDiarrheaConstipation

Stomach achesIrregular periods (for women)Migraines/headaches

Catch colds easilyAllergiesAsthma

Drink coffeeDrink alcoholSmoke cigarettes

Please list any vitamins or medications that you're currently taking:

Note: HealthFix values your privacy and the confidentiality of the information you choose to share. Any information collected is kept in a confidential, secure file, and is only accessible by HealthFix.